Andrew Hunter, Whitney Coffey, Evan Mobley, and Tanner Turley - - PowerPoint PPT Presentation

Andrew Hunter, Whitney Coffey, Evan Mobley, and Tanner Turley Bureau of Health Care Analysis and Data Dissemination

Trends and the ICD-CM Transition

NAS is a series of withdrawal symptoms

and other problems experienced by a newborn after exposure to narcotics via placenta or breastmilk.1

NAS can be caused by many drugs, but

• piates cause notably high rates of

neonatal withdrawal.1

13.7 15.1 12.9 12.4 12.4 12.3 21.6 24.6 21.8 21.3 21.1 20.8 0.0 5.0 10.0 15.0 20.0 25.0 30.0 2016* 2015 2014 2013 2012 2011 Crude Rate per 10,000 Residents

Opioid Misuse Emergency Department Discharges, 2011-2016*

Female, Ages 15-44 All Persons

* provisional data

0.00 5.00 10.00 15.00 20.00 25.00 30.00 35.00 2011 2012 2013 2014 2015 2016* Crude Rate per 1,000 Live Births

Missouri NAS Rates, 2011-2016*

* provisional data

Missouri’s NAS rates have increased

362%

in the past SIX years.

The Patient Abstract System (PAS) is a database maintained by the Department containing inpatient and outpatient records from Missouri’s non-federal hospitals and ambulatory surgery centers.

ICD-9-CM (2015) ICD-10-CM (2016) ICD-10-CM (2017) 2014-Q1 through 2015-Q3 2015-Q4 through 2016-Q3 2016-Q4 through present ICD- CM Code

76072 7795 P044 P0449 P961 P962 P044 P0449 P961 P962

Long Description

Narcotics affecting fetus or newborn via placenta

• r breast

milk Drug with- drawal syndrome in newborn Newborn (suspect- ed to be) affected by maternal use of drugs of addiction Newborn (suspect- ed to be) affected by maternal use of

• ther

drugs of addiction Neonatal with- drawal symp- toms from maternal use of drugs of addiction With- drawal symp- toms from thera- peutic use of drugs in newborn Newborn affected by maternal use of drugs of addiction Newborn affected by maternal use of

• ther

drugs of addiction Neonatal with- drawal symp- toms from maternal use of drugs of addiction With- drawal symp- toms from thera- peutic use of drugs in newborn

Missouri Resident NAS Rates by Type, 2014-2016*

• 76072. Narcotics affecting fetus or newborn via placenta or breast milk.
• P044. Newborn (suspected-to-be) affected by maternal use of drugs of

addiction.

• P0449. Newborn (suspected-to-be) affected by maternal use of other

drugs of addiction.

• P044. Newborn affected by maternal use of drugs of addiction.
• P0449. Newborn affected by maternal use of other drugs of addiction.

0.00 5.00 10.00 15.00 20.00 25.00 30.00 Q4 Q1 Q2 Q3 2016 2017 Crude Rate per 1,000 Live Births

Provisional Missouri Resident NAS Rates by Type, 2016-2017*

newborn affected by maternal use neonatal withdrawal Baseline is the 2015 annual NAS rate.

 NAS is not specifically caused by opioids, though maternal use of

this drug type does contribute to the majority of NAS cases.

 NAS cases may not always be directly attributed to maternal drug

use or misuse- in some cases opiates are used in pain management for newborns which can lead to rare cases of therapeutic withdrawal.

 Definitional changes and evolving surveillance definitions make it

difficult to track true change over time.

 Neonatal Abstinence Syndrome is a series of symptoms and

behaviors and there is not a single standard for diagnosis. Additionally, symptoms may present themselves up to 10 days after birth. This could lead to under- or over-estimates of NAS prevalence.

 NAS could be diagnosed in patients outside of a hospital or

emergency room setting and would not be captured by the PAS system.

St. Louis Metro female and family

centered treatment options:

• SSM Health WISH Center at St. Mary’s Hospital
• Queen of Peace Center
• Chestnut Health Systems (IL residents)
• Barnes-Jewish Hospital

This collaboration is partially funded by

Substance Abuse and Mental Health Services Administration (SAMHSA).

 CLINICAL GUIDANCE FOR

TREATING PREGNANT AND PARENTING WOMEN WITH OPIOID USE DISORDER AND THEIR INFANTS2

 Published by SAMHSA in

January 2018. Now available online.

• Detailed clinical guidance

and factsheets for stages of pregnancy.

 Prenatal Care, Infant Care, Maternal Postnatal Care

 1. Stanford Children’s Health. Neonatal Abstinence Syndrome.

http://www.stanfordchildrens.org/en/topic/default?id=neonatal- abstinence-syndrome-90-P02387.

 2. Substance Abuse and Mental Health Services Administration

(SAMHSA). Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants. https://store.samhsa.gov/shin/content//SMA18-5054c/SMA18- 5054.pdf.

Partnering with Local Medical Examiners and Coroners

 Enhanced State Opioid Overdose Surveillance

(ESOOS)

 National Violent Death Reporting System

(NVDRS)

 Missouri began participation in both programs

in September 2016.

 Both programs require coroner/medical

examiner (C/ME) cooperation to provide supplemental information not on the death certificate for fatal events.

 Toxicology  Narrative report

• Victim history
• Scene evidence
• Bystanders present?

 Autopsy/Pathology Exam

 Personal information scrubbed, only pertinent info

related to death recorded

 Example:

• Victim (V) was 31/Black/Male. Last seen alive at

2230 on 2/1/17. V was found unresponsive at 0900 on 2/2/17 in bed with syringe and spoon

• n nightstand. EMS arrived at scene at 0910 and

pronounced V dead. V had known history of heroin abuse over past 3 years. V had prior drug

• verdose within last month.

 Underlying Cause of Death Codes

• X40-44.9 (Accidental)
• Y10-Y14 (Undetermined)

 Contributing Cause of Death Codes

• Heroin: T40.1
• Opioids: T40.0, T40.2, T40.3, T40.4, T40.6
• T50.9 (Multi-Drug)

 Search across literal fields in the death certificate.

 In Missouri, the coroner and medical examiner

system is decentralized.

• Coroner vs Medical Examiner

 114 counties and one independent city

• Some counties consolidate under one medical

examiner (e.g. St. Louis, Kansas City)

 How do we focus our efforts?

 NVDRS - goal is statewide participation starting in

2018

 ESOOS - requires at least 75% of statewide deaths

to be reported

 Timeliness

• Initiation – Upload death certificate data

 6 months after reporting period

• Completion – Abstract C/ME records

 8 months after reporting period

 Opioid deaths largely in

metro areas. (60% in St. Louis and surrounding area)

 Target metro areas and

surrounding counties.

Blue = Participating Grey = Interested Year 1 Year 2

 Missouri Coroners’ and Medical Examiners’

Association (MCMEA)

 Encouragement from C/MEs currently

participating

 Other partners

• Law Enforcement, Local Public Health Agencies

(LPHAs), Drug Coalitions, etc.

 Mailer with NVDRS/ESOOS information

 Varying levels of detail in reports between

counties

• Toxicology Depth

 Contract process

• Involves multiple county officials

 Providing technical assistance to C/ME

Analyzing Emergency Department Use in Urban/Rural Areas

1 2 3 4 5 6 7 8 9 10 2011 2012 2013 2014 2015 2016 Crude Rate per 100,000

Resident Opioid Overdose Deaths by Type Missouri, 2011-2016

Non- Heroin Opioids Heroin

 How does opioid overdose morbidity

compare with mortality?

 How have ED visits due to opioid overdose

changed over time?

 Are there differences in rates and changes

• ver time between urban and rural areas?

 Heroin vs. Non-heroin opioids

• Non-heroin = prescription drugs (fentanyl,
• xycodone, OxyContin, etc.) and other

illicit opioids

 DHSS receives ED, inpatient, and outpatient data

from approximately 132 Missouri hospitals

 Records include info on patient demographics,

diagnoses, other visit information

 23 Diagnoses fields

• Coded in ICD-9-CM and ICD-10-CM
• First Diagnosis is primary reason for visit

 Enhanced State Opioid Overdose Surveillance

(ESOOS)

• Non-fatal Opioid Overdose Reporting

 ICD-9-CM and ICD-10-CM Definitions

• ICD-9: 965.XX codes and E850.X E-Codes
• ICD-10: T40 and F11

 6th character: (1,4) Accidental or undetermined  7th character: (A) Initial Encounter

 Array of first 5 of 23 diagnoses fields

 115 Counties in MO  2 Major Urban areas (St. Louis and Kansas City)  Lesser Urban areas (Springfield, Columbia, Joplin)

County Classification Description Number of Counties Large Central Metro (Most Urban) Metropolitan Statistical Area (MSA)

• f 1 million or more and contain

entire population of the principal city in the MSA

2

Large Fringe Metro MSAs of 1 million or more that are not Large Central Metro

14

Medium Metro MSA of 250,000 to 999,999

6

Small Metro MSA of less than 250,000

12

Micropolitan Counties in Micropolitan Statistical Areas

22

Noncore (Most Rural) Counties not in Micropolitan Statistical Area

59

Grand Total

115

0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 2012 2013 2014 2015 2016 Crude Rate per 10,000

Missouri Resident Opioid ED Visits by NCHS County Classification

Large Central Metro Large Fringe Metro Medium Metro Small Metro Micropolitan Noncore

Urban areas continue to have the

highest rates

Fentanyl vs Heroin

• ED visits due to heroin overdose have

increased drastically in all areas

• Fentanyl cannot be distinguished from other

synthetic narcotics by ICD code alone (T40.4)

• Fentanyl may not be as prevalent in rural

areas

 It could follow heroin trend and spread

 Participating in ESOOS

• Collecting more data in a timely manner

 Partnering with stakeholders

• Law enforcement, C/MEs, LPHAs, Department of

Mental Health, local coalitions, other DHSS units

 Prescription Drug Monitoring Programs (PDMPs)  Naloxone

• Standing order prescription, Grants for

distribution and training

 911 Good Samaritan Law

The Department’s Newest Dissemination Tool

 The Division of Community and Public Health has

developed a web-based dashboard to communicate data related to opioid abuse.

 Maps, charts, and other graphics tell the story of

the opioid epidemic in Missouri.

Dashboard Section 1

The Death Toll

The Death Toll

The Death Toll

The Death Toll

The Death Toll

Dashboard Section 2

An Epidemic Affecting Everyone

The Impact on the Future

 Andy Hunter

• Andrew.Hunter@health.mo.gov
• 573-526-0444

 Whitney Coffey

• Whitney.Coffey@health.mo.gov
• 573-751-6285

 Evan Mobley

• Evan.Mobley@health.mo.gov
• 573-522-1483

 Tanner Turley

• Tanner.Turley@health.mo.gov
• 573-751-6298